Acute myocardial infarction (AMI) is the leading cause of death in the US, and this year at least 600,000 Americans will be hospitalized for it at a cost of tens of billions of dollars in additional health care costs and lost productivity. Numerous health care organizations have developed guidelines for the care of these patients. But, these guidelines have been promulgated despite any validation that they can effectively improve patient outcomes or affect costs. This proposal is a research study that will validate national guidelines for AMI patients for angiography, coronary artery bypass graft (CABG) or percutaneous transluminal angioplasty (PTCA). The entire project will involve six research subprojects; five of these are designed to learn more about the multiple factors associated with processes of care and their relationship to guidelines and subsequent patient outcomes. The sixth is designed to compile and analyze data on successive cohorts (since 1987) of Medicare patients who have an AMI so that we can correlate their experiences with the introduction of changes in diagnosis and treatment during this period. In collaboration with HCFA and the Cooperative Cardiovascular Project the group will obtain detailed patient and hospital level data on a probability sample of nearly 8200 patients living in one of seven states. We will use these data to evaluate each patient's appropriateness for angiography and CABG or PTCA and will compare the extent to which adherence to guidelines affects outcomes (both health and financial). Health outcomes will include mortality and a variety of functional status and general health outcomes obtained from patient interviews l2 and 36 months post AMI. Appropriateness will be measured by American College of Cardiology and American Heart Association (ACC/AHA) and RAND guidelines. Cost-effectiveness analyses will be performed for over 40 typical patient presentations after an AMI and will lead to a comparison of guidelines created from a cost-effectiveness perspective with those created primarily from a clinical perspective. Finally, in order to understand possible reasons for non-adherence to the national guidelines by physicians, we will survey over 2000 cardiologists in seven states to understand their attitudes towards the use of these procedures in AMI patients.